‘The Health Workforce in India’, [1] a study published by the World Health Organization (WHO), reports the physician density in India to be around 0.8 physicians per 1,000 population against a norm of one physician per 1,000 population. While the delta might not look that alarming initially, the details do paint a dismal picture of healthcare services in India and a call to action on all fronts. According to this study, only 77% of the self-described physicians in India are from the allopathic stream while the rest are practitioners of alternative medicine such as ayurveda, homeopathy and unani. A more disturbing data point that the study highlights is that among all individuals listing their occupation as doctors, as many as 57% did not have a medical qualification. Further, the study reports an urban to rural physician density ratio of 4:1 and an enormous variation in the density of healthcare workers across states. These imbalances reflect the public healthcare crisis in the country. While the government of India is planning to open 15 new All India Institutes of Medical Sciences (AIIMS) and 22 new medical colleges, these institutions will take time to establish and produce qualified doctors who can fill the shortage.

Amidst this healthcare crisis, it is exciting to encounter a new breed of soldiers — entrepreneurs armed with new business models and technology — who are ready to disrupt and change the healthcare playing field. The Internet, smartphones, smart medical devices, online marketplaces and analytics are a few of the digital technologies that have led to the unbundling of various health services that were previously offered only through hospitals.

It was my privilege to speak with one such soldier, Jagdeep Gambhir, CEO and Co-founder of Karma Healthcare. An ISB alumnus from the PGP Class of 2012, Jagdeep talks about the idea behind his start-up and the opportunities and challenges they have faced on their journey.

Reema: How did the idea of leveraging technology to provide healthcare services in rural India come about?

Jagdeep: When we started out, our thinking was that if you can use digital connectivity to find a laundry in Vasant Kunj, why can’t you use the same technology to provide healthcare to somebody in a remote rural area of Rajasthan? This gave birth to the idea of Karma clinics, a physical clinic managed by a nurse who facilitates a video consultation between a patient and a doctor. So, a patient who used to travel about 100 kilometres to seek a doctor in, say, Udaipur, can now seek the same level of care one kilometre from her home using an online digital platform. And we have created software around that. It drastically improves the care available to this population.

Reema: Medical services delivery is a large and complex field that has traditionally operated on a high-touch business model. Did you focus on a specific area? And what are the challenges you have faced?

Jagdeep: It is primary care. Going into our business model context, when you open a clinic, you have to make sure that the services are limited and optimise whatever resources are there. So you cannot open a dental clinic in a rural area because there are not many people there to use the services; it is a distributed set-up. Instead, you have to open a clinic where you offer a range of services so that different people can come and access them . Essentially what we do is that we offer primary care and some levels of secondary care that can be provided over a digital platform. The concept of telemedicine has been around for some time, but our challenges are unique. Poor resources, low skills, and the distribution and density of the population are challenges, as are also caste and class issues. There are hundreds of challenges that we face on a day-to-day basis. So it is hard work. The fact that we have been persistent and are still alive is an achievement in itself, and by the way, we have treated about 50,000 patients.

Reema: Can you share with us your revenue model? How do you make this business sustainable?

Jagdeep: We actually charge patients. The idea is that for a patient in a rural area, his current options are either to go to a quack and pay about INR 400 to 500 on average — much more than we charge, or seek the same level of care that we provide digitally from a doctor in a city that might be 100 km away, which would typically cost the patient Rs. 2000. We can do that for Rs. 150 in our clinic, so that is one-tenth the cost. We said that if we can create a business around this idea, we can eventually scale it up. So the idea was not to create a non-profit, but to create a sustainable business where accountability and incentives are aligned. We have nine clinics; six are in Rajasthan. And then we were invited by the President of India to replicate our work in the villages that he has adopted. For a young, struggling start-up, that has given us a lot of visibility and credibility. We were named winner of the UBS Social Innovators 2016 programme by UBS and Asoka. It was an idea that we could potentially scale and disrupt. There is a strong focus on quality and a strong focus on how we can do that right.

Reema: Can you talk about a few key components of your technology that differentiate you from other telemedicine service providers? Many other business models such as mobile clinics or a centralised call-in triage process have been tried in India, but very few have been able to scale.

Jagdeep: If you look at our organisation as an organism, technology is the backbone but employees are our senses. Our model is an assisted care model; it is not like a health ATM. There is a human being who will facilitate a video consultation between a patient and a doctor. So if I am a rural customer, I don’t go and use a computer on my own. I seek care from a local nurse who is actually a local villager. Our successes are directly correlated with the quality of the nurses that we have. What we can do with technology, what we have now created is something like a clinical decision support system. In a few months, I will have the ability to rank my doctors because we track patient data right from patient information to his complaints, diagnosis, prescription, fees, etc. We can use a lot of that data to actually make healthcare much more transparent.One of the other things that we are trying to do now is to increase the range of services. There are already medical devices available that we can integrate into our clinics and on to our system. There is a product that allows you to actually screen for diabetic retinopathy which we can use in our clinic, and we can now also add ophthalmology here to a certain extent. Linkage to a secondary or a tertiary care process is another critical part of value delivery that can be bridged using technology.

The key is that technology is an enabler. But you need to make sure that your nurse is trained, you need to make sure that your organisation values compassion and that it values human beings in a certain way.

Reema: This business model is a classic case of a two-sided platform. On one side, there are individuals with healthcare needs, and on the other side, there are healthcare professionals who can service the need. We have spoken at length about the value of the platform for the rural patient, but what is in it for the doctor? How do you motivate a doctor who could earn Rs. 500 for the same consultation in an urban area to come to this hub and work for less?

Jagdeep: We have a shared services model wherein we actually believe there is excess doctor capacity in private urban areas. We are utilising this spare doctor capacity so that the doctor makes more money. It has to make business sense. We don’t have any doctors directly on our payroll. We actually provide a pool of doctors and then we have to follow the code of ethics, the rules and regulations, etc. The system tries to ensure that patients are linked to the same doctor again and again so that the experience is seamless.

Doctors come on the platform and give us a specific amount of time, for example, they may say, ‘I am available from 3 pm to 6 pm every day, ’ or ‘I am available from 3 pm to 6 pm on Monday, Wednesday and Friday’. It is essentially the same thing as having regular clinic hours, only that rather than being physically present, the doctor is online during that time. We have doctors consulting from Delhi and Udaipur who are treating patients in different states. The clinical system will ensure there is an audit trail that can be reviewed for malpractice.

Reema: Scaling is considered to be one of the biggest challenges any start-up faces. Many claim that doing proof of concept is easy, but the true entrepreneurial challenge is in scaling the business model. What are the biggest challenges your organisation will face as you scale from nine villages in one state to 1,000 or 10,000 villages across India?

Jagdeep: The good news for us is that we do not have demand-side challenges; we are more constrained on the supply side. We currently have offers from 50 different clinics pan-India. The key challenge in scaling is how you scale compassion. Because on the technology side, you can get three more servers and you can see a hundred times the patient volume, but as I said, servers are not going to solve India’s healthcare problem. How do you create an organisation that scales compassion? And again, with digital technology, how can you make it much more transparent? This is a leadership issue. People have done it and we hope to be able to do it.

As a start-up, I think we face a lot of challenges. If you really want to do something disruptive, I think the criticism and the challenges are there. We face some resistance from the government, we find resistance from unqualified and untrained providers, and we face some resistance from hospitals. But I think if we speak to 100 people, 95 are supportive and five are not. But access to talent, access to quality people — smart people who are not trying to build an app that does online laundry but an app that does online healthcare — is a challenge. We actually pay very good salaries, but people have to understand that there is life beyond financial remuneration as well, and that there is no greater joy than in saving somebody’s life and we do this every day.

Reema: Talking about creating impact, tell us a bit more about areas where you have had impact and potential areas in healthcare services that are ripe for disruption.

Jagdeep: I think our biggest impact is using technology to empower the patients and nurses and give them control of their health outcomes. There are women who come to our clinic, are attended by a nurse, seen by a doctor who is again female, 75 kilometres away, for a gynaecological ailment that she has been suffering from for a month. She can do all this without leaving her village. I think that can only be done via technology. You can’t stop those ideas when the time comes. If we don’t do it, somebody else is going to do it. It is just a responsibility and there is a cost for inaction.But the bigger impact is going to be through digital technology. If you can actually digitise everything that is going on, then you can do a lot of audits and you can put in a lot of controls, and I think that is what is going to truly disrupt the field more than the physical face-to-face consultations.The potential and the opportunities are huge. I was looking at emergency medical services and I was wondering why we are not doing all of this. We are limited only by our imagination and actually by our skill set!